<?xml version="1.0" encoding="UTF-8"?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"/>
        <title>{TITLE}</title>
    </head>
    <body>
        <button onClick='history.go(-1)'>Back</button>
        <p>
            <form method="POST" action="{ACTION}">
            <table class="tbl_case_review" align="center" width="75%" border="0" cellpadding="4">
                <tbody>
                    <tr>
                        <td valign="top">
                            <!-- name, address, etc. fields go in here -->
                            <table border="0" cellpadding="1">
                                <tr>
                                    <td>
                                        {FNAME}
                                    </td>
                                    <td>
                                        {MNAME}
                                    </td>
                                    <td>
                                        {LNAME}
                                    </td>
                                </tr>
                            </table>
                            <table border="0" cellpadding="1">
                                <tr>
                                    <td>
                                        {CITY}
                                    </td>
                                    <td>
                                        {STATE}
                                    </td>
                                    <td>
                                        {ZIP}
                                    </td>
                                </tr>
                            </table>
                            <table border="0" cellpadding="1">
                                <tr>
                                    <td>
                                        {CONTACT_NAME}
                                    </td>
                                    <td>
                                        {FDMSCASE}
                                    </td>
                                    <td>
                                        {FDMSVITALS}
                                    </td>
                                </tr>
                            </table>
                        </td>
                    </tr>
                    <tr>
                        <td colspan="3">
                            {NOTE}
                        </td>
                    </tr>
                    <tr>
                        <td align="right" colspan="2">
                            <!-- [clear] and [submit] buttons -->
                            <!-- {SUBMIT_BUTTON} -->
                        </td>
                    </tr>
                </tbody>
            </table>
            </form>
        </p>
    </body>
</html>
